Q&A: Myocardial injury query template
Q: My facility does not have a template for a non-traumatic myocardial injury query. Would the following, in your opinion, be an appropriate query?
Dear _______ MD, Hospital Med
There is an opportunity for clarification within the patient record. Can you please clarify the documentation?
Please indicate your response to the query by documenting your response below.
HELPFUL NOTE: Nonischemic myocardial injury (non-traumatic)
DEFINITION: The term acute nonischemic myocardial injury applies to patients with active rising and/or falling cardiac troponin (cTn) concentration but lacking clinical evidence of myocardial ischemia. Underlying causes can include acute heart failure, direct injury due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), myocarditis, or stress cardiomyopathy.
Primary noncardiac etiologies may include acute or chronic kidney disease or failure, hypertensive urgency, valvular heart disease, paroxysmal tachycardia or Takotsubo syndrome, pulmonary embolism or hypertension, or critical illness such as sepsis.
Clinical Indicators: Patient with troponin values out of normal range per EPIC values (0.011-> 0.056-> 0.037). Elevated troponin documented. Nonischemic EKG documented.
To reflect your patient's accurate severity of illness and risk of mortality, please clarify the diagnosis associated with your patient’s "elevated troponin."
_ Nonischemic myocardial injury due to acute illness (pneumonia, acute hypoxemic respiratory failure, acute heart failure with reduced ejection fraction)
_Other (please specify):
_Another diagnosis (please comment):
Treatment: lab (brain natriuretic peptide, troponin), monitoring by hospitalist, cardiology, OT, PT, SLP, RD consults
Per EPIC LAB:
troponin 0.056-> 0.037
POC troponin 0.11
bnp 40,700 on 22 SEP
23 SEP CARDS ___ PA "Mildly elevated troponin - flat (0.011, 0.056, 0.037). No chest pain, nonischemic EKG. Does not appear to be ACS, likely 2/2 to stress under acute illness. Patient's goals of care to be discussed today palliative care, patient is DNR. Likely no aggressive care."
4. 23 SEP Dr ____ "Elevated troponin - Suspect due to hypoxia in setting of CHF.
Trop 0.11 -> 0.056 -> 0.037
Cardiology consult as above”
Risk Factors: Diagnosed with pneumonia, acute hypoxemic respiratory failure, decompensated heart failure with reduced ejection fraction, dementia, atrial fibrillation, hyponatremia
If you have any questions, please contact clinical documentation specialist _____ at _____. Thank you.
*********THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD*********
The definition of nontraumatic myocardial injury is included in the query, as it seems our providers are not familiar with this diagnosis. At times, demand ischemia, elevated troponin, or indeterminate troponin is documented by the providers. Can you please provide rationale of whether this is a compliant query or not?
A: I can appreciate your question. For any query concerns, we should look to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief. On p. 9, it says the following:
“Clinical indicator(s)” is a broad term encompassing documentation that supports a diagnosis as reportable and/or establishes the presence of a condition. 5 Examples of clinical indicators include (but are not limited to): provider observations (physical exam and assessment), diagnostic tests, treatments, medications, trends, and consultant documentation authored by providers and ancillary professionals documented throughout the health record. There is no required number of clinical indicator(s) that must accompany a query because what is a “relevant” clinical indicator will vary by diagnosis, patient, and clinical scenario. While organizations, payers, and other entities may establish guidelines for clinical indicator(s) for a diagnosis, providers make the final determination as to what clinical indicator(s) define a diagnosis.
Clinical indicators should:
- Be clear and concise
- Directly support the condition requiring clarification
- Allow the provider to clinically determine the most appropriate medical condition or procedure
- Paint the clinical picture of the diagnosis queried to be added or clinically validated
- Be specific or directly related to, but not necessarily from, the current encounter (see Role of Prior Encounters in Queries, above)
- Support documentation that will translate to the most accurate code
Clinical indicator(s) may be sourced from the entirety of the patient’s health.
In your query template, the indicators do include reference of what should be included; however, it may be excessive and not necessarily support the query question. On p. 11 of the query practice brief, it says:
A query should not direct (lead) the provider to document a specific response (e.g., highlighting, bolding, underlining, italics, using a yes/no format to obtain a new diagnosis). It is non-compliant to continue sending the same query to the same or multiple providers until a desired response is received.
On p. 20:
Q: Is it allowable to include definitions within a query? For instance, a query for afib specification including definitions for the type of atrial fib? Or a query for CKD staging including the ranges of stage differentiation?
A: Including such information on a query is common. This practice allows providers ease in access to organizationally developed diagnostic criteria or industry evidence-based guidelines. This practice is not thought to be leading. The information should be provided without any indication of choice, meaning the information should not highlight, bold, or indicate a desired answer.
In your example, providing definitions of the condition of myocardial injury would be considered leading if it is not already documented within the medical record. On p. 12 of the practice brief, it says:
Multiple choice query formats should include clinically significant and reasonable option(s) as supported by clinical indicator(s) in the health record, recognizing that occasionally there may be only one reasonable option. Providing a new diagnosis as an option in a multiple-choice list—as supported and substantiated by referenced clinical indicator(s) from the health record—is not introducing new information. There is no mandatory or minimum number of choices necessary to constitute a compliant multiple-choice query.
You can just have one choice with the additional “other” choice. In your example, you have two “other” choices, so one is not required.
Best practice would be to list the clinical indicators, present your question, and list your multiple-choice responses. For example:
Dear _______ MD, Hospital Med
To support severity of illness and accuracy of documentation, the following clarification is needed. If you could please review and document your response in the medical record.
Documentation states pneumonia, acute hypoxemic respiratory failure, decompensated heart failure with reduced ejection fraction, dementia, atrial fibrillation, hyponatremia
Nonischemic EKG documented.
Labs: troponin 0.056-> 0.037, POC troponin 0.11, BNP 40,700 on 22 SEP
PN: 23 SEP CARDS "Mildly elevated troponin - flat (0.011, 0.056, 0.037). No chest pain, nonischemic EKG. Does not appear to be ACS, likely 2/2 to stress under acute illness. Patient's goals of care to be discussed today palliative care, patient is DNR. Likely no aggressive care."
PN: 23 SEP "Elevated troponin - Suspect due to hypoxia in setting of CHF. Trop 0.11 -> 0.056 -> 0.037
Please clarify the diagnosis based on the above clinical findings.
Nonischemic myocardial injury due to the acute illness
Elevated troponin due to hypoxia in setting of CHF
Other explanation of clinical findings (please specify)
If you have any questions, please contact clinical documentation specialist _____ at ____. Thank you.
*********THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD*********
Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, director of CDI education at ACDIS/HCPro, answered this question. Contact her at deanne.wilk@hcpro.com.